Provider Demographics
NPI:1366443640
Name:AGRAWAL, SUBODH K (MD)
Entity type:Individual
Prefix:
First Name:SUBODH
Middle Name:K
Last Name:AGRAWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6032
Mailing Address - Country:US
Mailing Address - Phone:706-208-9700
Mailing Address - Fax:706-208-0806
Practice Address - Street 1:2005 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6032
Practice Address - Country:US
Practice Address - Phone:706-208-9700
Practice Address - Fax:706-208-0806
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028344207RS0012X, 208VP0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00414554EMedicaid
GA060047315OtherRR MEDICARE
D44683Medicare UPIN
GA06BDFSBMedicare ID - Type Unspecified